Nokea
A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?
- A. I'm sorry but your son's medical information is none of your business.
- B. The healthcare provider will share this information with you.
- C. I can only give medical information to your son because he is an adult.
- D. I will get these results back from the lab as soon as possible.
Correct Answer: C
Rationale: The best response for the nurse to provide is 'I can only give medical information to your son because he is an adult.' Since the client is 19 years old and considered an adult, the nurse must respect the client's right to privacy and confidentiality.
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A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
- A. Change coccyx dressing after performing routine care.
- B. Change coccyx dressing before performing routine care.
- C. Restate the vital importance of performing hand hygiene.
- D. Perform coccyx dressing change in the nursing station.
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate.Which action should the nurse take to evaluate the client for urinary retention?
- A. Review the chart for number of voids over the last 24 hours.
- B. Evaluate the client for urinary incontinence.
- C. Scan the client's bladder after voiding.
- D. Palpate the suprapubic region for distention.
Correct Answer: C
Rationale: This will help determine if there is any residual urine left in the bladder after voiding.
A client presents to the doctor's office with a report of fatigue and difficulty sleeping.Which information should the nurse recognize as a potential contributing factor?
- A. Reads a book entitled 'How to Sleep Better'.
- B. Exercises in the morning and afternoon.
- C. Consumes antibiotics twice a day.
- D. Sleeps between 10 PM and 9 AM each night.
Correct Answer: C
Rationale: Antibiotics can have side effects that may contribute to fatigue and difficulty sleeping.
The nurse is planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.